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Q2: The word "placebo" is used differently by different people. Some suggest that placebo is that which has no effect. I never liked that sort of definition because if there is no effect, then it's senseless to speak of a placebo response or a placebo effect. How do you define placebo?

__________________"I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

Q3: Spinal manipulation has received quite a lot of attention from the research community and I've heard it described as "low hanging fruit" for researchers due to its popularity within the culture and evidence base. What would you consider to be high hanging fruit for physical therapists?

__________________"I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

At the AAOMPT lecture, I recall you suggesting that the total effects of improvement after manual therapy could be attributed to a combination of natural history, placebo mechanisms, and then other mechanisms. Could you elaborate on this topic further and discuss study designs and processes that might answer some of these questions?

We have a thread here called "More than Placebo" in which we discussed some of those issues and that our readers (and perhaps Dr Bialosky) would like to review:More Than Placebo

Given the research to date, do you feel there is support for the position taken by some in the manual therapy community, that there are some specific effects of particular manual therapy methods beyond placebo or nonspecific mechanisms?

Thanks Dr Bialosky, I simply want to start by saying I look forward to reading most of your research. They keep me motivated.

Sorry, my Q1 is long.
Q1 : Placebo has, in part, an opioid mechanism. In the late 90' and beguining of the 2K period, studies on SMT have tried to see if SMT had an opioid mechanism. In these studies, naloxone failed to block immediate SMT analgesia and SMT did not seem to show tolerance to repeated administration.

These studies led the researchers to conclude SMT did not have an opioid analgesic mechanism to achieve the immediate effect on pain thresholds.

TENS had also failed to see its effect blocked by naloxone in past studies until this month's article in PAIN. It seems prior studies used an insufficient dosage of naloxone which did not block all the opioid receptors. That would have prevented the blocking of delta-opioid receptors. In this month's PAIN article, they used a higher dose of naloxone and successfully blocked the immediate TENS alagesia by doing so. They hypothethized TENS works, at least in part, through a delta-opioid receptor mechanism.

Finally, my questions are : Do you think, provided the right dosage of naloxone is used, SMT's initial analgesic effect could be blocked with naloxone? Would that demonstrate SMT works through an opioid mechanism? If so, is this effect reflecting mostly the placebo response or a specific mechanism?

__________________
Frédéric Wellens, pht«We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
«Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.»Friedrich Nietzschewww.physioaxis.cachroniquesdedouleur blog

Q2 : It has been shown that SMT and manual therapies have an immediate analgesic effect on pain. Do you think this immediate effect is related to outcomes? That is, would eliminating this effect actually block the positive effects on outcomes?

__________________
Frédéric Wellens, pht«We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
«Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.»Friedrich Nietzschewww.physioaxis.cachroniquesdedouleur blog

Q3 : how much of the biomechanical model do you think should be salvaged ?

Q4 : Despite the fact the biomechanical models has many flaws, most of the research still focuses on treatment technics or applications directly derived from this model. It's just that the focus is now on the neurophysiological mechanisms behind these traditionnally biomechanically oriented treatments.

Should'nt we try to find better/new ways to achieve these, and superior, neurophysiological effects instead of constantly revisiting the same ones, actually invented along the lines of a biomechanical paradigm?

Q5 : Do you think, these mechanically oriented treatments maintain their popularity because they fit nicely in the patients and therapists' default belief system?

__________________
Frédéric Wellens, pht«We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
«Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.»Friedrich Nietzschewww.physioaxis.cachroniquesdedouleur blog

My thanks also to Dr. Bialosky for taking the time to indulge us with his participation in this interview.

I have two questions for now- one is about a specific construct for conceptualizing assessment and treatment of MSK pain problems, and the other is a general question about the future of the physical therapy profession.

1. In our previous interview here with your mentor, Dr. Steven George, he made this statement:

Quote:

There is some interesting data from our lab suggesting similar effects [to SMT] on temporal summation are observed following neural mobilization techniques, so there may be some potential of this phenomenon being generalized across different manual therapy techniques...

Have you looked at this more closely in the lab, and what role do you see for neurodynamics as both an intervention and explanatory model in manual therapy?

2. Given the depth of understanding that you and your research partners have gained as a result of the research you've undertaken in manual therapy mechanisms, how confident are you that the profession of physical therapy will embrace these findings and modify its traditional roots in the orthopedic/biomechanical model? And as a follow up, what do you think will be the consequences if we don't?

__________________John Ware, PTFellow of the American Academy of Orthopedic Manual Physical Therapists"Nothing can bring a man peace but the triumph of principles." -R.W. Emerson“If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
be carried on to success.” -The Analects of Confucius, Book 13, Verse 3

I read with interest your paper on spinal manipulation efficacy and expectation.
How do we go about validating a tool such as that?
Do you feel this is a response mediator variable such that future trials of manual therapy should collect this and report it between groups to attempt to control for its influence?

My question for you is that it seems difficult not to avoid any placebo effect when doing research. How are we as readers, not researchers not too be misled by the result of any research?

In you experience, which following will bring about more placebo effect when the client comes to see us? The physio's reputation, dress, interpersonal communication skills, clinical reasoing skills, manual skills... anything else.....??/
Thank you

My question is in regards to your Guest Editorial in JOSPT, June 2008. What negative effects do you see could come about in the delivery of Spinal Manipulative therapy without proper and accurate (at least to the best of our current knowledge) education to the patient of why it works?

In a thread here about manual therapy and placebo, one therapist stated essentially that there were no specific effects of manual therapy and that they were all placebo mediated responses. What would response to that concept be?

__________________
Frédéric Wellens, pht«We often refuse to accept an idea merely because the tone of voice in which it has been expressed is unsympathetic to us.»
«Those who cannot understand how to put their thoughts on ice should not enter into the heat of debate.»Friedrich Nietzschewww.physioaxis.cachroniquesdedouleur blog